Professional freedom

SIR,-I read with interest the paper by Mr R A B Wood and Professor L E Hughes on the above subject (18 October, p 131) and would like to make the following conuments. The disadvantages of permitting an excised wound to iheal by "packing and granulation" are those of prolonging healing time (inpatient and outpatient), delaying wound contractions, and promoting repair by tissue that is weaker and dissimilar to that which surrounds it. The application of such a method of treatment should thus be examined very critically before being used on wounds made in the proximity of bone in particular-namely, the sacrococcygeal region -and pressure sores. The resulting epithelisation may adhere to bone and suffer frequent breakdown. Treatment for sacrococcygeal pilonidal sinus by the Z-plasty or rotation flap repair permits complete healing within 8-14 days (normal healing for trunk wounds). Any arguments that favour the "lay open and pack" technique serve only to advance a method that requires considerable outpatient attention. The recurrence rates for all forms of treatment for this condition vary from O to 300'o, being highest for wounds repaired by simple closure and approximately zero for repair by flaps.'-4 As a new technique in packing, the apparent advantages of silicone foam elastomer are (a) pain-free removal and (b) plasticity. May I therefore suggest that its principal application is as an obturator to retain biological or other dressings in elderly patients whose general debility precludes a general anaesthetic for major flap or skin graft surgery. Even those among us who are "packing" enthusiasts will have observed that wound aftercare-change of dressings, medicated baths, and regular attendance at clinics-tends only to encourage patients to prolong their convalescence unless they are self-employed. Basic human attitudes are unlikely to alter significantly by substituting silicone foam for the conventional gauze pack. Moreover, the silicone sponge may yet prove the more expensive. S C SOOD Guy's Hospital, London SEl

Looking at the skin SIR,-I read with ever-increasing agreement your leading article, "Looking at the skin" (25 October, p 189). As you unfolded your arguments the principles of good dermatological practice were extolled. However, the clinical example chosen as an exception to these rules, "obviously localised lesions like a rodent ulcer," was perhaps unfortunate and prompts this comment.
It has been known for a number of years that patients suffering from the rare basal cell naevus syndrome, in which skeletal abnormalities and a liability to other tumours such as medulloblastoma occur, may present to the skin physician with a "localised lesion like a rodent ulcer." Furthermore, the elderly patient with a rodent ulcer, even when this occurs on a light-exposed site, has an enhanced likelihood of having other malignant skin tumours on non-exposed sites and of malignant disease in general. Over the past nine years I have detected several early breast cancers during my routine physical examination of patients with solitary basal cell carcinoma.
There should be no exception to the rule that every patient attending a skin department should have a physical examination which involves looking at the whole of the skin. One can even produce arguments to justify the procedure in cases of virus warts, but space does not permit.
ROY The results of our published study on hyperlipidaemic patients (4 January, p 17) and those of our studies (submitted for pub-Professional freedom SIR,-The article by Dr P Kekki on the changing status of doctors in Finland (1 November, p 273) was chilling and obviously puiblished with a shrewd sense of timing.
Is it not now time to spell out unequivocally that what is at stake in our interminable disputes with both political parties-the Conservative administration being only marginally less awful than the Labour-is not money, hours of work, and conditions of employment, but something much dearer to the politician's heart-power.
Surely it is now obvious to most people that what is going on is a plan to emasculate the power of the professions, which has, in the past, been not inconsiderable. The proliferation of the administrators is not accidental. It is a cynical plan to swamp the professions by weight of numbers and reduce their influence to the minimum. Overworked doctors have not time to sit on lengthy committees.
Salmon was not an ill-conceived attempt at reorganisation. It was a very adroit manoeuvre to curb the power of the nurses' professional body by reducing their numbers and by making a proportion of them "administrators"-that is, by making them change sides and by demolishing the authority of the ward sister. Numbers have been partially restored by the employment of nursing aides, who are less of a political threat to the administration. The device has succeeded only too well. The same is now rhappening to the physiotherapists in the appointment of physiotherapy aides, who, I understand, are not markedly less well paid than their fully qualified counterparts. As soon as the qualified physiotherapists become outnumbered by the aides their influence will comnensurately decrease. lication elsewhere) on patients subjected to certain common environmental stresses showed a significant positive relationship between the microsomal enzyme y-glutamyl transpeptidase and serum triglyce,ride levels but a negative relationship between serum y-glutamyl transpeptidase and cholesterol levels which was not statistically significant. It is of interest here to note that Cucuianu et all found a highly significant positive relationship between serum pseudocholinesterase and triglyceride levels but not between serum pseudocholinesterase and cholesterol levels. Because the rate-liriting enzymes of cholesterol synthesis and breakdown are situated in the microsomes the effect of enzyme inducers on the serum cholesterol level is not predictable.
We also feel, in agreement with the earlier suggestion of Cucuianu et al,. 2 that any liver stress resulting in altered rates of protein synthesis can lead to corresponding alteration in the rate of production of the microsomal enzymes of lipid synthesis and/ or the carrier lipoproteins. Even Aneurin Bevan in one of his more unguarded moments said, "Politics . . . is about power." The professions must now urgently recognise the nature of the attack which is being mounted against them and unite to defeat it. lhis is nothing less than a survival issue. At the moment, it is the medical professions which are the target. Once they have been reduced to the status of docile employees it will be the turn of the lawyers, and when they succumb, truly we shall be living in a totalitarian state.

C D FISHER
Saltney, Chester SIR,-In his Nigel Colley Memorial Lecture to the Nottingham Division of the BMA Sir Geoffrey Howe said that he was prepared to advocate substantial reforms in the present organisation of the legal profession because "a growing number of voices had been heard to complain of the failure to meet the demands of a mass population for legal advice." The inaccessibility of lawyers and solicitors contrasts strangely with the general availability of the medical profession (even in these difficult times). As a general practitioner I regularly see patients whose problems are related to housing, social security, and, sadly, loss of job. Many of them would undoubtedly benefit from legal advice, but they are deterred from consulting a solicitor either through ignorance or fear of the cost. Despite 27 years of the welfare state the legal profession has managed to maintain its full professional independence-a situation which most lawyers would defend whatever their political allegiance in party terms. BRITISH MEDICAL JOURNAL 22 NOVEMBER 1975 The legal profession in the UK is an example of unfettered free entenprise. It is true, of course, that legal aid is available, but it makes little impact on the average citizen.
Liberty is one essential aspect of the definition of a profession, based as it is upon the concept of service. Yet at this time the Government and Labour Party are obsessed with eliminating the last vestigial remnants of professional freedom from the medical profession. In contrast, however, there are no Government proposals at all to meet the demands of a mass population for legal advice.
Can While we are aware that the rapid changes which have occurred in Western society have led to the introduction of trade union attitudes in many professions, we believe that they are totally unsuited to medicine. The responsibilities and activities of doctors cannot be regulated by the clock or fitted into standard hours. Medicine is a contemplative, liberal profession and for the majority of doctors must be a way of life rather than a means of earning a living on an hourly basis. Did the majority of doctors and do medical students take up medicine to become wageearning shift workers?
Until very recently it has been accepted that newly qualified doctors work excessively long hours in the care of their patients and in this way they gain experience which cannot be obtained in any other manner. Limited hours and shift work must sooner or later lead to administrative interference to control the mounting costs, thereby further diminishing the training and experience of junior staff and resulting ultimately in an unprofessional clock-on, clock-off working day. The principle of a closed contract and overtime pay must encourage a mercenary attitude among doctors which could dominate their concern for their patients and their interest in their jobs. It could have the effect of jeopardising and corrupting the future development of medicine in the United Kingdom and especially the high standard of patient care ,Which has been built up over the past century.
We believe that there is still time for the profession to think again and for our negotiators to be instructed to return to the principle of the open contract based on an appropriate annual salary. Leadership from among those who share our views will be necessary. Only in this way can the inde-pendence and professional standing of medicine be preserved. R D CATTERALL

MARY CATTERALL London W8
Private practice and the NHS SIR,-One of the most disturbing and potentially far-reaching aspects of the present upheaval within the Health Service is the degree to which the profession has been unable to put across the fundamental issues underlying the unrest. This is not to infer that the facts have not been voiced, but rather that, for various reasons, their significance has not been widely comprehended. To explain this situation it is not helpful to blame others-such as a biased press, a popular approach of some of our political leaders-but rather it behoves us to look to ourselves for the reasons. The question of private medicine is an emotive one with many widely held beliefs relating to it. The most significant of these is surely that its very existence will have a deleterious effect on the provision of medical care available to the large majority of the community not making use of its facilities. If the profession is to gain general support it must be seen to have clearly understood this fact, and, rather than making contentions which might at best appear abstract or irrelevant and at worst largely concerned with self-interest, it is important that the central theme of our argument should relate to the welfare of the NHS patient. By insisting on this as the frame of reference in which the debate is to be conducted we ensure that it is the profession and not the Government who are seen to be protecting the health care interests of the community. Having focused attention on the real factors limiting the provision of services within the NHS, the reasons for the sincerely held belief that the NHS itself derives benefit from its mutual coexistence with the albeit relatively small private sector must be more carefully explained. Also a willingness should be shown to make those provisions necessary to ensure that abuses of the system do not occur.
A simple but sound definition of a good medical care system is one in which both the consumers and providers of care are basically satisfied, and in contrast, no matter how ideal the system may appear to be for either party, it will clearly be manifestly unsuccessful if the other is essentially dissatisfied. Few will argue that until recently the NHS has managed, within the constraints of its considerable underfunding, to provide a commendable service with a high level of costeffectiveness compared with other Western countries. This was achieved in no small measure by the dedication and sense of vocation of those working within it. What evidence there is would suggest that this has been well recognised and appreciated by the community as a Whole and it is from them that the profession should draw its strength and support L I ZANDER Pay freeze and superannuation benefits SIR,-The freeze on salaries at £8500 per annum will prevent many of us from purchasing added years or increased lump sum as permitted in the NHS superannuation scheme. A public relations exercise between the Government (Department of Health and Social Security) and the medical profession would be beneficial to both parties and would also indicate that the Government is not completely antagonistic to the profession and particularly the ihospital consultants. The suggested exercise relates to the present salaries held by the Government as either frozen annual incremental payments or as salaries over the £12 500 limit as proposed in the last pay review. These moneys have been taken into account by the DHSS in that pension assessment will be as if the money had been paid. However, the wiv-thholding of these moneys will prevent many of us from purohasing either added years or increased lump sums as a protection for our retirement and dependants.
It appears to us to be a simple fiscal exercise for the withheld moneys to be paid by the DHSS directly into the superannuation scheme for the purchase of added years oy added lump sum. The consultants would not receive the money (in line with Government policy) and the benefit received would be in the future, in the forn of added security to our pensions and dependantsagain in line with Government policy.
It would seem that if the increments that we are anticipating are not paid, then few consultants can take the option of purchasing added years or increased lump sum